Delayed traumatic subcutaneous emphysema: a case report

Abstract

Background: Subcutaneous emphysema is a common, usually benign, and self-limiting complication of traumatic chest wall injury. In a minority of thoracic injuries, pneumothoraces can result in extensive subcutaneous emphysema and subsequent airway obstruction if air tracks along tissue planes within the neck. Furthermore, patients may have a delay to presentation following chest-wall injury and can rapidly decline. Hence, we discuss a case of delayed traumatic subcutaneous emphysema resulting in airway compromise, without cardiorespiratory compromise from tension pneumothoraces.

Case presentation: A white British female in her 70s attended the emergency department 24 h after a fall at home with the complaint of right sided chest pain and shortness of breath. On arrival, the patient appeared well, with no sign of compromise. The patient rapidly deteriorated over the course of the next 30 min. Massive crepitus swelling was identified of her upper and lower limbs, head (including palpebral closure), neck, chest, and abdomen. Vocal changes and early airway obstruction features were identified. Prompt recognition of rapidly progressive subcutaneous emphysema with airway compromise, early rapid-sequence induction, chest-drain insertion, and a multidisciplinary team approach ensured a positive outcome, with discharge home after 12 days in hospital.

Conclusion: Subcutaneous emphysema itself is rarely life-threatening, though it can infrequently manifest as an obstructive airway emergency. Delayed presentations are possible, and the presence of subcutaneous emphysema indicates severe chest-wall injury. Airway protection and treatment of pneumothoraces are critical interventions for these patients.

Keywords: Case report; Emergency medicine; Intensive care; Pneumothorax; Subcutaneous emphysema; Trauma.

Fig. 1

An anteroposterior portable chest X-ray taken in the resuscitation room post-intubation, demonstrating severe subcutaneous emphysema. Pneumothoraces and are not appreciable in this image, due to overlying emphysema

Fig. 2

Axial computed tomography showing emphysema surrounding the larynx and laryngeal edema (arrow 1)

Fig. 3

Axial computed tomography showing emphysema penetrating the deep neck tissues (arrows 2 and 3)

Fig. 4

Axial computed tomography showing the right-sided moderate-volume pneumothorax (arrow 4) and the right-sided lower-lobe pulmonary hemorrhage (arrow 5)

Fig. 5

Axial computed tomography showing the left-sided moderate-volume pneumothorax (arrow 6) and the left-sided lower-lobe laceration and collapse (arrow 7)